| Dental Cleaning - Adult | $109 | N/A | $109 |
| Dental Cleaning - Child | $88 | N/A | $88 |
| Dental Exam - Comprehensive | $149 | N/A | $149 |
| Dental Exam - Periodic, Established Patient | $51 | N/A | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $169 | N/A | $169 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $321 | N/A | $321 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | N/A | $286 |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | N/A | $164 |
| Dental Filling - White (Resin): One Surface, Posterior | $207 | N/A | $207 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $371 | N/A | $371 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | N/A | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | N/A | $231 |
| Fluoride - Topical Application | $45 | N/A | $45 |
| Maintenance Therapy - Periodontal | $173 | N/A | $173 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $158 | N/A | $158 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $463 | N/A | $463 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | N/A | $102 |
| Root Canal - Anterior Tooth | $1,044 | N/A | $1,044 |
| Root Canal - Bicuspid Tooth | $1,220 | N/A | $1,220 |
| Root Canal - Molar | $1,399 | N/A | $1,399 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $120 | N/A | $120 |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | N/A | $200 |
| X-Ray - Complete Intraoral Series | $184 | N/A | $184 |
| X-Ray - Four Images, Bitewings | $78 | N/A | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $62 | N/A | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $187 | N/A | $187 |
